5801 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE-BALL POINT,PEN ONLY
• BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
BUILDING p) pp APPLICATION & PERMIT
ADORES s/Q�KJ o F6. •.� . . - '5801
(//yLCLa P;45#1VA) A"W ,7011 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S -
NAME
�De77
Later vHprvE QTV PLAN CHECK VALIDATION
I ELECTRIC PERMIT FEE
ArvrnacrORs
NA ME
gME OUTLETS-SWITCHES-RECEP, 5.00/1.00 -
1-4reo /pG 6C.Np, LIGHTING FIXTURES 5.00/1X0
CONTRACTOR'5
ADDRESS / 7Jpp' APPLIANCES-RESIDENTIAL 4.00 '
698 IF,7Ayco7G 4vel PHONED szs_/c) PANELS 5.00
ARCHITECT GATE OF APPLICATION '
_
' OR SIGN$ ° g:QO 'PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNSTRANS. 3.00
aRCH.ORENG.
appRE55 -I_MP..METER
IAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP ORP E INS.. 15.00'AvvucarvrsSEE FEE SCH.APPLICA ORSE VICE CH GE _ 10.00
F C o LICENSED CON'fRACTOkS DECLARATION -
a U U I hereby affirm that I am licensed under provisions of Chapter 9
h Q m (COmmencing with Section 7000)of Division 3 of tileISSUANCE DATE Business and BLDG. ELECT, PLG. MECH.
H w z Professions Code y licenf
se is in ull fore Miff
,o i rn License,�laK f CoLic.Number �/.7; El ❑ ❑ res
,A H Dale-�f nlmclor
4 /E(
¢_ la,a OWNER-BUILDER DECLARATION BUILDING PERMIT
INFORMATION
E:
3' I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
•H .. o¢ Law liar t h e following reaStln.(SPC.70'1 if emadleocndnue I'a" PERMIT ISSUANCE - - vALuaTION $/FT.
Cade:Any city or county which re uiresa 6.00 ,
lc ^i 2 4 permit to construch all c', ELEC.CONTR. LIC.NO.
a D improve,demolish,pr repair any structure,prior to its issuance,also ELEC.
requires the applicant for such permit to file a signed statement that TOTAL'
a w w he is licepsed pursuant W the Provisions of(he Contractor'
s Licenu PERMIT TO
HiQ Law fChapter9(commencing with Sect inn 7000)0FDPision 3 of the MI
app
4 4 o Business and Professions Codc)or that IT is exempt Therefrom and QTY. PLUMBING PERMIT FEE
L H S the basis for the alleged exumptipn.Any violation of Section 7031.5 STORIES TYPE CONSTR.
3 _ by any applicant for a permit subjects the0) Iman-0.lett penally ALTER-DRAIN&VENT-WATER
of not more than five hundrcJ dollars(5500).1: (EA.)'q.00
❑ I,.as owner of the Property,or my employees with wages as BACK FLOW PROTECT.DEVICE-
onsole'compensalion,will IS Olc work,and the structure is nut 2. OCC.GROUP RES.UNITS
on
or offered for sale(Sec. 7G44, Business and Professions - DRAINS-FLOOR,ROOF,ARE/{,CON D.. .00
Code:The Contractor's License Law does not apply m an owner of -
property who builds Of Improves thereon,and who does such work FIXTURES-PER TRAP, V40000 `5D.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided,that such improve- -
meats arc not intended or Offered for sale If,however.the building GAS-EA.SYSTEM-1 INC.4 OUT TS 4.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im. GAS-EA.SYSTEM-OVER 4 A.1 1.00 BUILDING USE
prove for purpose ofsaleJ. INDUSTRIAL WASTE INT - RES ' IND CON PS Omar
❑ I,as owner of ole Property,am exclusively contracting with
licensed contractors io construct the project(Sec.7044,Business LAWN SPRINKLERS-1 �'. ❑ C3C'5.V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's Licenw.Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS OVER 5(EAT 1.00
contracts for such projects with a contractors)licensed pursuant to -
the Contractor's License Law, - SEWER-SANITAR -STORM -EA.ZOOft/B.00 TRACT rvo. PARCEL No.
mason am exempt under See. ,B.&P.C.for this WATER'HEAT W/VENT
Owner 4.00 .
• Dale WATER SVS M 4.00 ACC.OATE', ACC.FILE NO.
WORrnn thaCOhiivc a ATION DECLARATION WATER T EATING EQUIP, t 4.00 ' •
I hem Oy ate of or I have m e Compensation
in consent or
censure
co a certificate(Sec
Workers'Compensation Insurance,or a certified - - ZONING ENG.SITE NO. :
copy thereof lSe..JBOQ Lab P,lny M10 /4JpFZ(,p/Y
Policy No,__Company '
Q ❑ Certified copy iss III furnish d. - - •' r FIRESPRINK ENERGY T-24
Z Z CertiNee��¢py rs fi wi h ci inspection division. - "
FO APPllcant_Q/i,QT�@o�_ MISC- - REFER TO ORD. Y=Q N❑ YE] NQ
CERTIFICA1 H OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE FLOOD ZONE. a.L.u.c.
W COMPENSATION INSURANCE PLG.CONTH. LIC.NO. . ' .
1 o IThis,ecchou need not be completed if the permit is for one PLGTOTAL Y�; NO V N�
Z hundred dollars(SI00)or less.) '
U O 1 certify that in the..performance of the work for which thisper- OTV MECHANICAL PERMIT FEE FEE SUMMARY
Iy U mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
tl Date ApplicantALTER OR ADD T 4,00 On ' 'BUILDING
} to NOTICE TO APPLICANT: If,after making This Certificate of Ex-
� ? eniptiun,you should become subject to.the Workers'Compensation APPLIANCE 4.00 ' PLAN CHECK
provisions of lite labor Code, you must Ibrlhwilh comply with -
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT IT 10 1 3,00 FEE
CONS'TRUCT'ION LENDING AGENCY AIR HANDLING R10 . -M.15.00 "SEISMIC FEE
-
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD WIT U 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNI .Ti 4.00
Lenders Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and stale that the have VENTILATION FAN (SINGLE) 3.00
mlormation is Correct.I agree to comply with all city and county
ordinances and state laws relating Ho building construction, and BOILER-COMP(3H.P.or100,000B.T.U,) 4.00 ,PLUMBING
of
hereby authorize representatives talivas eco is,city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspersion purposes. MECHANICAL
.. .(we) agree to save, indemnify and keep harmless[he City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City In consequence of the PERMIT ISSUANCE ' 3.00 $•�
grant of this permit: MECH.CONT.- '" .LIC.NO.. MECH.
l�tl
r •I�9. 4 �4 / CH.CO TOTAL -
SignaloreofApp ant�Co(/ ctor Dale Kr''^' /��/ 3/.y31�6,. �. TOTAL
%.91
OFFICE COPY.